Idea to take the 'D' out of PTSD being studied

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The president of the American Psychiatric Association says he is "very open" to a request from the Army to come up with an alternative name for post-traumatic stress disorder so that troops returning from combat will feel less stigmatized and more encouraged to seek treatment.

Dr. John Oldham, who serves as senior vice president and chief of staff at the Houston-based Menninger Clinic, said he is looking into the possibility of updating the association's diagnostic manual with a new subcategory for PTSD. The subcategory could be "combat post-traumatic stress injury," or a similar term, he said.

"It would link it clearly to the impact and the injury of the combat situation and the deployment experience, rather than what people somewhat inaccurately but often assume, which is that you got it because you weren't strong enough," Oldham said.

The potential change was prompted by a request from Gen. Peter Chiarelli, the Army's vice chief of staff, who wrote to Oldham last year, suggesting APA drop the world "disorder" from PTSD.

"Calling it a disorder contributes to the stigma and makes it so some folks -- not all, but some folks -- don't get the help they need," Chiarelli said.

The general doesn't like to use the word disorder. "It's not a dirty word, but I think it's misused here," he said. "I don't think that the post-traumatic stress that soldiers experience is a disorder. It's not something that happens just to weak people or people that are somehow inclined to be affected by horrible things that they see or are required to do. I think it causes an actual injury to the brain and how the brain works."

Early discussions

After receiving Chiarelli's letter, Oldham wrote back to say he appreciated his concern, but dropping the word disorder might not be the best way to go. He said he was eager to work with Chiarelli to see what APA could do.

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The general invited Oldham to the Pentagon to discuss the situation. They met for about an hour and a half on Dec. 9. Oldham agreed to bring the general's suggestion to the APA work group tasked with reviewing PTSD for the next version of the association's Diagnostic and Statistical Manual of Mental Disorders, the classification book used by psychiatrists in America. APA is finalizing the fifth edition of the manual, due in May 2013.

Oldham cautioned the discussion is very preliminary but speculated that a new subcategory like "combat post-traumatic stress injury" might work.

Although Chiarelli still would prefer to lose "disorder" entirely, he said a new subcategory would be a start. "I'm frustrated with how long this is taking to be honest," he said.

The general pointed out that PTSD has had many names over the years, from shell shock to battle fatigue. "It's been called all kinds of different things and somehow we decided to go with PTSD and I think that's just wrong," he said.

Chiarelli's campaign to change the name of PTSD is part of the Army's effort to reduce alarming suicide rates among soldiers. Statistics released last month identified 260 potential suicides in 2011. Of that total, 154 were active-duty soldiers, 73 were National Guard troops and 33 were reservists.

Silence over stigma

Stigma is a major problem. A study published in the Archives of General Psychiatry in October found that soldiers were two to four times more willing to report PTSD, depression, and suicidal thoughts if they were allowed to answer a survey anonymously, rather than put their names on a routine post-deployment screening form.

Of the soldiers who screened positive for PTSD or depression, 20 percent said they weren't comfortable answering honestly on the routine form. The study concluded that the Army's screening process misses most soldiers with significant mental health problems.

Dr. Harry Croft, a psychiatrist in San Antonio, said the findings jibe with what he hears from veterans he treats for PTSD.

"Even though the rules, as I understand them, say you don't get kicked out if you get diagnosed with PTSD, depression or any other issues, a lot of veterans say, 'I knew damn well if I answered the questions right my chance to get promoted was gone,' " Croft said.

Croft has mixed feelings about changing the name of PTSD. He understands the concern about stigmatizing troops but thinks whether the condition is called PTSD or something else will have little effect on the suicide rate.

"Rather than concentrate on what we call it, we need to concentrate more on how to help warriors coming back from the combat zone, because I don't think the name we give it will have much of an impact on the 18 suicides a day and all the other problems that we see," Croft said. "That's putting a Band-Aid on a much bigger wound."

Chiarelli says his main concern is getting soldiers into treatment, so if calling post-traumatic stress a disorder keeps them from seeking help, then the wording needs to change, the sooner the better.

"You can have the very, very best treatments in the world, but if you can't get people take advantage of them, they don't do any good," he said.
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